Smaller Nodule Size Research Articles

Post-CT-guided lung biopsy optimisation of the observation period by identifying patients at risk of delayed pneumothorax.

Identify the risk factors for delayed pneumothorax after lung biopsy. A retrospective study of 355 CT-guided lung biopsies was performed at Fiona Stanley Hospital, Western Australia over 42 months. A comprehensive range of patient, lesion and procedural variables were recorded. All post-procedural complications including time, size of pneumothorax and post-biopsy radiographs were reviewed. Lasso logistic regression model was utilised to determine factors predicting patient complications. A total of 167 patients (47%) developed a pneumothorax, in which 34% were significant, requiring longer observation or drain insertion. The majority of pneumothoraces occurred within the first hour (86%), with 90% detected at the time of the procedure. Then, 12% were detected more than 3 h post-procedure, of which 8 patients (5%) had a significant delayed pneumothorax. Factors increasing the likelihood of significant pneumothorax include the length of lung traversed, smaller nodule size, surrounding emphysema, increased age and lateral patient position with the lesion in the non-dependent aspect. Increasing patient age, longer length of lung traversed and smaller nodule diameter increase the risk of delayed onset of pneumothorax (more than 3 h). The results of this study align with other studies indicating it is safe to discharge stable patients within an hour post-lung biopsy. However, specific risk factors, including age, small lesion size and deep lesions, may identify patients who could benefit from a longer observation period.

Incidence and risk factors for pulmonary hemorrhage after percutaneous CT-guided pulmonary nodule biopsy: an observational study

To evaluate the current incidence of pulmonary hemorrhage and the potential factors contributing to its increased risk after percutaneous CT-guided pulmonary nodule biopsy and to summarize the technical recommendations for its treatment. In this observational study, patient data were collected from ten medical centers from April 2021 to April 2022. The incidence of pulmonary hemorrhage was as follows: grade 0, 36.1% (214/593); grade 1, 36.8% (218/593); grade 2, 18.9% (112/593); grade 3, 3.5% (21/593); and grade 4, 4.7% (28/593). High-grade hemorrhage (HGH) occurred in 27.2% (161/593) of the patients. The use of preoperative breathing exercises (PBE, p =0.000), semiautomatic cutting needles (SCN, p = 0.004), immediate contrast enhancement (ICE, p =0.021), and the coaxial technique (CoT, p = 0.000) were found to be protective factors for HGH. A greater length of puncture (p =0.021), the presence of hilar nodules (p = 0.001), the presence of intermediate nodules (p = 0.026), a main pulmonary artery diameter (mPAD) larger than 29 mm (p = 0.015), and a small nodule size (p = 0.014) were risk factors for high-grade hemorrhage. The area under the curve (AUC) was 0.783. These findings contribute to a deeper understanding of the risks associated with percutaneous CT-guided pulmonary nodule biopsy and provide valuable insights for developing strategies to minimize pulmonary hemorrhage.

The role of inflammatory parameters in the management of cases with atypia of undetermined significance/follicular lesions of undetermined significance

AIM: This study aimed to evaluate the potential of hematologic parameters and markers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and systemic inflammation response index (SIRI) to predict the risk of malignancy in patients whose biopsy results were classified as Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (AUS/FLUS).
 MATERIAL AND METHOD: A total of 188 patients who underwent thyroidectomy at a General Surgery clinic were included in the study. Hematological parameters, including neutrophil count, platelet count, lymphocyte count, monocyte count, and mean platelet volume (MPV) were collected from the hospital database. NLR, PLR, MLR, SII, and SIRI were calculated. Statistical analyses were performed using SPSS v25. 
 RESULTS: 38 patient (20.21%) were male and 150 patients (79.79 %) were female. The mean age was 48.6 (range 23-79, standard deviation (SD) ± 12.41years). Histopathological examination of the thyroidectomy specimens revealed benign findings in 102 patients (54.3%) and malignant findings in 86 patients (45.7%). The mean age of the malignant group was 45.6, while that of the benign group was 51.1 (p = 0.02). The median tumor size was 17 mm in the malignant group and 21 mm in the benign group (p =0.042). Mean neutrophil count were 4.29 ± 1.0 × 109/L in the benign group and 4.69 ± 1.9 × 109/L in malignant group, respectively (p = 0.031). NLR values were calculated as 1.89 for the benign group and 1.99 for the malignant group (p = 0.045). SII values were higher in the malignant group, with a median value of 584.11× 109/L in the malignant group, median value were 504.63× 109/L in the benign group (p=0.037). 
 Multivariate logistic regression analysis revealed that both age (odds ratio (OR) = 0.964; 95% confidence interval (CI)= (0.939 – 0.989); p = 0.05) and neutrophil count (odds ratio (OR) = 1.598; 95% confidence interval (CI)= (1.118 – 2.285); p = 0.01) had a significant impact on the differentiation between benign and malignant thyroid nodules.
 CONCLUSION: Age and neutrophil count were identified as independent risk factors for malignant thyroid nodules. Among patients with Bethesda Category III thyroid nodules, those under 59.5 years of age and with a neutrophil count above 4.16 x 10^9/L have an increased risk for thyroid malignancy.
 Platelet count, monocyte count, MPV and inflammatory parameters, such as PLR, MLR, and SIRI, were insufficient for detecting malignancy in Bethesda III nodules. In this group, young age, small nodule size, high neutrophil count, NLR, and SII were identified as risk factors for malignancy. The Thyroid Imaging Reporting and Data System (TI-RADS) characteristics of nodules should also be considered in the management of these patients.

Effect of selection for growth rate on the rabbit (Oryctolagus cuniculus) immune system and its response after experimental Staphylococcus aureus infection.

The aim of the work was to evaluate if genetic selection for daily gain may affect the immune system. Two experiments were performed. The first one involved 80 rabbit females and their first two litters to explore the effect of selection on the ability of animals to maintain immune competence. Two generations from a line selected for average daily gain (ADG) were evaluated (VR19 generation 19th, n = 43; VR37 generation 37th, n = 37). In females, the effect of selection and its interaction with physiological state were not significant for any trait. In litters, the selection criterion increased the granulocyte to lymphocyte ratio. The second experiment involved 73 19-week-old females (VR19, n = 39; VR37, n = 34) to explore the effect of genetic selection on immune response after S. aureus infection. The VR37 rabbit females had lower counts for total lymphocytes, CD5+, CD4+, CD8+, CD25+, monocytes, the CD4+/CD8+ ratio and platelets than those of VR19 (-14, -21, -25, -15, -33, -18, -11 and -11%, respectively; P < 0.05). VR37 had less erythema (-8.4 percentage points; P < 0.05), fewer nodules (-6.5 percentage points; P < 0.05) and a smaller nodule size (-0.65 cm3 on 7day post-inoculation; P < 0.05) compared to VR19. Our study suggests that genetic selection for average daily gain does not negatively affect the maintenance of a competent immune system or the ability to establish immune response. It seems that such selection may improve the response to S. aureus infections.

Factors influencing the total procedure time of CT-guided percutaneous core-needle biopsies of lung nodules: a retrospective analysis

PURPOSE This study aims to investigate the factors that influence total procedure time when performing computed tomography (CT)-guided percutaneous core-needle lung biopsies. METHODS This is a cross-sectional study of 673 patients, who underwent a CT-guided percutaneous coreneedle biopsy at a tertiary care center from March 2014 to August 2016. Data on patient, nodule, and procedural factors and outcomes were collected retrospectively. Univariate linear regression and a multivariate stepwise linear regression were utilized for analysis. RESULTS Factors most strongly associated with prolonged procedure duration include 20-gauge needle use when compared with 18-gauge needle use (estimated difference in time=1.19), collecting additional core biopsies (estimated difference in time=1.10), decubitus nodule side up (DNSU; estimated difference in time=1.42), and supine positioning (estimated difference in time=1.16) relative to decubitus nodule side down positioning, and increased nodule distance from the skin surface (estimated difference in time=1.03). Increased nodule length (estimated difference in time=0.93) was associated with reductions in procedure duration. Prolonged procedure time was associated with an increased rate of pneumothorax (odds ratio (OR)=1.02; P < .0001) and decreased rate of pulmonary hemorrhage (OR=0.97; P < .0001). CONCLUSION The use of 20-gauge biopsy needle, collecting additional core biopsies, DNSU and supine positioning, smaller nodule size, and increasing nodule distance from the skin surface were associated with increased procedure time for CT-guided core needle biopsies of lung nodules. Prolonged procedure time is associated with a higher rate of pneumothorax and a lower rate of pulmonary hemorrhage.

Risk Factors for Malignancy in Patients with Multinodular Goiter.

Introduction The identification of thyroid cancer may be conducted through clinical detection, imaging method, and histopathological examination. Both solitary nodules and multinodular goiter are associated with malignancy. Objective To assess the risk factors for malignancy among patients with multinodular goiter submitted to total thyroidectomy. Methods A series of 712 consecutive patients, submitted to total thyroidectomy between 2005 and 2016 with multinodular goiter regarding clinical, ultrasound, and pathological variables, was retrospectively evaluated. Results There were 408 cases of papillary carcinoma (57.3%), with the remaining being benign. Gender had no statistical significance ( p = 0.169) for malignancy, unlike the Bethesda index, higher age group ( p = 0.005), shorter clinical history time ( p = 0.036), smaller number of nodules ( p < 0.0001), and smaller nodule size ( p < 0.0001), which were related to malignancy. Conclusion The Bethesda index, older age group, shorter clinical history, smaller number of nodules, and smaller size of nodule were related to the diagnosis of papillary carcinoma.

Abstract 5232: Next-generation sequencing revealed clonal architecture and faciliated diagnosis of patients with multiple lung tumors: An analysis of 12 cases

Abstract Diagnosing multiple lung tumors as multiple primary lung cancer (MPLC) or intrapulmonary metastasis (IPM) has important therapeutic implications. The clinical applicability of next-generation sequencing (NGS) has been explored, although there is currently no consensus regarding how to integrate its findings for cancer staging. We performed a retrospective analysis of the mutational landscape of 13 patients with multiple tumors and underwent surgery at Renmin Hospital of Wuhan University from Sep. 2018 to Dec. 2020.The cohort consisted mostly of women (11/13, 84.6%) and non-smokers (12/13, 92.3%). Median age was 58 years (range 26-71). No patient manifested relapse after a median follow-up duration of 11.2 months (range 8.2-36.0). NGS was performed with a large panel (≥ 350 genes) in most cases (11/13, 84.6%). Most nodules were invasive adenocarcinomas (25/41, 61.0%), followed by adenocarcinomas in situ (13/41, 31.7%), and minimally invasive adenocarcinomas (3/41, 7.3%). Four patients were clinically diagnosed with IPM, of whom 1 had only one nodule sequenced. Of the 12 patients with genomic profiles from multiple nodules, 10 (83.3%) had consistent NGS inference and clinical diagnosis of MPLC or IPM. Of the remaining two, P1 was clinically diagnosed with IPM but NGS did not detect any genomic aberrations from one nodule, which may have missed evidence that could have led to inference of clonal relationship. P8 was diagnosed with MPLC but had two nodules that harbored EGFR L858R mutation. NGS revealed clonal relationships that enabled high-confidence differential diagnosis in the concordant cases. For instance, the 3 nodules in P10 each harbored an oncogenic driver: EGFR exon 19 deletion, EGFR L858R, and ALK fusion, which were suggestive of tumor clones of separate origins. Similar mutual exclusion was also observed in P6 (EGFR exon 19 deletion vs L858R), P2 (EGFR exon 19 deletion vs MAP2K1), and P7 (2 EGFR exon 18 mutations G719A and E709 in one nodule vs EGFR E746_A750del in another). On the other hand, P9 illustrates a case of complex clonal architecture, in which 8 nodules were derived from 5 origins. Further analysis found that alterations in KRAS were associated with smaller nodule size, whereas those in TP53, CDKN2A, NKX2-1, or GNAS were associated with greater size.In summary, NGS achieved highly concordant MPLC/IPM differentiation with clinical diagnosis based on histopathologic and radiographic evidence. However, caution is warranted when NGS detects no aberration from any of the multiple sequenced nodules. Examination of the mutational landscape found that altered proto-oncogene KRAS was associated with smaller tumors whereas altered tumor suppressors TP53 and CDKN2A associated with smaller ones, suggesting different roles in these molecules play in tumor growth. Citation Format: Wenyang Jiang, Wei Wang, Luting Qiu, Xiao Zou, Zhiqiu Chen, Qing Geng. Next-generation sequencing revealed clonal architecture and faciliated diagnosis of patients with multiple lung tumors: An analysis of 12 cases [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5232.

CT-Guided Percutaneous Cryoablation in Patients with Lung Nodules Mainly Composed of Ground-Glass Opacities

PurposeTo assess the safety and efficacy of cryoablation in patients with lung nodules mainly composed of ground-glass opacities (GGOs). Materials and MethodsIn this retrospective study, 50 patients (mean age, 65.0 years ± 12.3; 28 women) with a diagnosis of lung GGO nodules who underwent cryoablation were included (from June 2016 to June 2021). The local recurrence rate, incidence of regional metastases to lymph nodes, incidence of distant metastases, adverse events, and lung function condition were analyzed. ResultsFollow-up computed tomography (CT) was performed at a mean of 33 months (range, 3–60 months) after the cryoablation procedure. Outcomes were only evaluated in 30 patients. A total of 20 patients were excluded. Of these 20 patients, 10 patients had no cancer detected by histopathological analysis and a diagnosis was made using CT or positron emission tomography (PET)-CT, The other 10 patients had nodules with a diameter of <10 mm and a consolidation-to-tumor ratio of >0.25; thus, histopathological analysis was not performed because of the small nodule size, and patients were diagnosed using CT or PET-CT. The local recurrence rate was 0% (0 of 30). Evidence of regional metastases of lymph nodes was not found in any patients (0%; 0 of 30), and the incidence of distant metastases was 0% (0 of 30). No major adverse events were noted. Lung function recovered to normal within 1 month after cryoablation in all patients. ConclusionsCryoablation may serve as a safe and feasible option for the treatment of lung nodules mainly composed of GGOs.

Facing Thyroid Nodules in Paediatric Patients Previously Treated with Radiotherapy for Non-Thyroidal Cancers: Are Adult Ultrasound Risk Stratification Systems Reliable?

Simple SummaryThe risk of thyroid nodules harbouring cancer has been evaluated, in adults, using specific ultrasound criteria. However, it is unclear whether such evaluation can be translated in paediatric patients. In this study, we tested the effectiveness of three known risk evaluation systems in children with thyroid nodules and with a history of radiation exposure. We found that these systems are reliable in confirming or ruling out cancer in most cases, except when evaluating very small nodules (<1 cm). For these reasons, these risk criteria should be adopted to account for the reduced size of malignant lesions when evaluating paediatric subjects.Thyroid nodule ultrasound-based risk stratification systems (US-RSSs) have been successfully used in adults to predict the likelihood of malignancies. However, their applicability to the paediatric population is unclear, especially in children with a history of radiation exposure, who are at a higher cancer risk. We tested the efficacy of three US-RSSs in this setting by retrospectively applying three classification systems (ACR-TIRADS, ATA and EU-TIRADS) to all paediatric patients referred for thyroid nodules and with a radiation exposure history. We compared the results with a reference standard (pathology or 36-month follow-up); sensitivity, specificity, positive and negative predictive values (PPV and NPV) and accuracy were calculated. A total of 52 patients were included; fourteen of them (27%) had papillary thyroid cancer (PTC) at the final histology. No significant differences across the US-RSSs were detected; specificity (range 95–97%) and NPV (range 88–93%) were particularly elevated. However, ACR-TIRADS, ATA and EU-TIRADS did not indicate the need for a biopsy in six (42.8%), seven (50%) and eight (57%) cases of PTC; in five cases, this lack of indication was due to a small (<1 cm) nodule size. In conclusion, US-RSSs show a high NPV and specificity in paediatric patients, whereas the cytology indication could be improved by reconsidering the dimensional criterion.

Preoperative prediction of non-invasive follicular thyroid neoplasm with papillary-like nuclear features: a Canadian single-Centre experience

BackgroundAn international group of experts recommended reclassifying non-invasive follicular variant of papillary thyroid cancers (FVPTC) as ‘non-invasive follicular thyroid neoplasm with papillary-like nuclear features’ (NIFTP) in April 2016. The purpose of this study was to establish preoperative clinical, laboratory, ultrasonographic, and cytological variables, which can differentiate NIFTP from FVPTC.MethodsWe conducted a retrospective chart review of consecutive patients from a single institution evaluated between January 2012 and December 2017. 203 adult patients underwent lobectomy or total thyroidectomy for a FVPTC during that period. Each patient’s medical chart was reviewed and information on pre-operative variables was recorded. An expert pathologist reviewed all surgical specimens and reclassified a subset of FVPTC as NIFTP according to the specific criteria.ResultsOverall, 44 patients were included in the NIFTP group and 159 in the non-NIFTP group. Mean age was 50.1 years in the NIFTP group and 50.7 in the non-NIFTP group. Most patients were female (86.4% (38/44) in the NIFTP group vs 79.8% (127/159) in the non-NIFTP group). More patients underwent lobectomy in the NIFTP group (50% (22/44) vs 16.4% (26/159) in the non-NIFTP group, p = < 0.0001). Less patients received radioactive iodine in the NIFTP group (31.8% (14/44) vs 52.2% (83/159) in the non-NIFTP group, p = 0.0177). Preoperative thyroglobulin levels were lower in NIFTP patients (Median 25.55 mcg/L +/− 67.8 vs 76.06 mcg/L +/− 119.8 in Non-NIFTP, p = 0.0104). NIFTP nodules were smaller (Mean size 22.97 mm +/− 12.3 vs 25.88 mm +/− 11.2 for non-NIFTP, p = 0.0448) and more often solid than non-NIFTP (93.2% (41/44) vs 74.8% (119/159) for non-NIFTP, p = 0.0067). 2017 ACR TIRADS nodule category of 1–4 on ultrasound had a negative predictive value and a sensitivity of 100% for NIFTP. ROC Curve Analysis demonstrated that a preoperative thyroglobulin level of 31.3 mcg/L had a sensitivity of 75% and a specificity of 62.5% to differentiate NIFTP from non-NIFTP cancers.ConclusionLower preoperative thyroglobulin levels, smaller nodule size, solid texture and 2017 ACR TIRADS Category of 1–4 are more strongly associated with NIFTP than FVPTC and can favour less invasive surgical options such as lobectomy.

Abdominal wall endometriosis: An 11-year retrospective observational cohort study.

ObjectiveThe objective of this study was to review the records of patients with excised abdominal wall endometriosis (AWE) to determine patient characteristics, diagnostic methods, presence of concurrent pelvic endometriosis and type of surgery.Study designMedical records from an 11-year period were searched to identify histologically confirmed AWE cases. Descriptive data were collected and analyzed. Two subgroups were differentiated: isolated AWE and pelvic endometriosis-associated AWE.ResultsThirty-five women with AWE were included. The most common symptom was cyclic abdominal or parietal pain (68.6%); 17.1% of the women had no symptoms. Twenty-nine women (82.8%) had a history of gynecological or obstetrical surgery, most commonly cesarean section (CS). The mean interval between prior surgery and appearance of symptoms was 5.3 years. Six women (17.1%) had no prior surgery; all six presented with umbilical nodules, nulliparity and confirmed mild to severe pelvic endometriosis. Among all patients, 34.3% had concurrent pelvic endometriosis, 40% presented with isolated AWE and 25.7% had no pelvic exploration. Women with concurrent pelvic endometriosis had significantly lower parity, smaller nodule size and a higher likelihood of umbilical location than those with isolated AWE (p < 0.05). A history of CS was more commonly found in women with isolated AWE. The overall recurrence rate over the study period was 11.4%, with a mean follow-up period of 5.2 years.ConclusionsAWE is an uncommon condition associated with long diagnostic and therapeutic delays. In patients with umbilical AWE and no surgical history, pelvic endometriosis is commonly present and should be highly suspected.

Thyroid cancer detection rate and associated risk factors in patients with thyroid nodules classified as Bethesda category III.

BackgroundUltrasound guided fine-needle aspiration (FNA) is a standard procedure for thyroid nodules management and selecting patients for surgical treatment. Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS), as stated by The Bethesda System for Reporting Thyroid Cytopathology, is a diagnostic category with an implied malignancy risk of 5–15%. The aim of our study was to review cytology and histopathology reports, as well as clinical and ultrasound data, for thyroid nodules reported as AUS/FLUS, in order to evaluate the malignancy rate and to assess factors associated with malignant outcome.Patients and methodsA total of 112 AUS/FLUS thyroid nodules in 105 patients were evaluated, of which 85 (75.9%) were referred to surgery, 21 (18.8%) were followed-up by repeat FNA and 6 nodules (5.3%) were clinically observed. Each was categorized in two final diagnostic groups - benign or malignant, which were further compared to clinical data of patients and ultrasonographic features of the nodules.ResultsFinal diagnosis of malignancy was reached in 35 cases (31.2%) and 77 (68.8%) had benign lesions. The most frequent type of cancer was papillary thyroid carcinoma (PTC) - 58.1% PTC and 25.8% had follicular variant of PTC. Patients’ younger age, smaller nodule size, hypoechoic nodule and presence of calcifications were shown to be statistically significant risk factors for malignancy.ConclusionsThe rate of malignancy for the AUS/FLUS diagnostic category in our study was higher than estimated by the Bethesda System. Clinical and ultrasound factors should be considered when decision for patient treatment is being made.

Computer tomography guided lung biopsy using interactive breath-hold control: a randomized study.

Interactive breath-hold control (IBC) may improve the accuracy and decrease the complication rate of computed tomography (CT)-guided lung biopsy, but this presumption has not been proven in a randomized study. Patients admitted for CT-guided lung biopsy were randomized to biopsy either with (N=201) or without (N=206) IBC. Biopsy accuracy, procedure time, radiation, and complications were compared in the two groups. Predictors for pneumothorax were analyzed. Procedures performed with the use of IBC (N=130) did not show higher biopsy accuracy (P=0.979) but were associated with a higher risk of pneumothorax (P=0.022) compared to procedures without the use of IBC (N=171). Overall, 50% of the biopsies were malignant, 13% were benign, and 33% were inconclusive (4% missing). Long needle time (P=0.037) and small nodule size (P=0.001) were predictors of pneumothorax. The use of IBC for CT-guided lung biopsy was not an advantage for unselected patients in our care, since it did not improve the biopsy accuracy and the risk of pneumothorax was increased.

Computed tomography (CT)-compatible remote center of motion needle steering robot: Fusing CT images and electromagnetic sensor data

Lung cancer is the most common cause of cancer-related death, and early detection can reduce the mortality rate. Patients with lung nodules greater than 10 mm usually undergo a computed tomography (CT)-guided biopsy. However, aligning the needle with the target is difficult and the needle tends to deflect from a straight path. In this work, we present a CT-compatible robotic system, which can both position the needle at the puncture point and also insert and rotate the needle. The robot has a remote-center-of-motion arm which is achieved through a parallel mechanism. A new needle steering scheme is also developed where CT images are fused with electromagnetic (EM) sensor data using an unscented Kalman filter. The data fusion allows us to steer the needle using the real-time EM tracker data. The robot design and the steering scheme are validated using three experimental cases. Experimental Case I and II evaluate the accuracy and CT-compatibility of the robot arm, respectively. In experimental Case III, the needle is steered towards 5 real targets embedded in an anthropomorphic gelatin phantom of the thorax. The mean targeting error for the 5 experiments is 1.78 ± 0.70 mm. The proposed robotic system is shown to be CT-compatible with low targeting error. Small nodule size and large needle diameter are two risk factors that can lead to complications in lung biopsy. Our results suggest that nodules larger than 5 mm in diameter can be targeted using our method which may result in lower complication rate.

Lung Nodule Volume Quantification and Shape Differentiation with an Ultra-High Resolution Technique on a Photon Counting Detector CT System.

A new ultra high-resolution (UHR) mode has been implemented on a whole body photon counting-detector (PCD) CT system. The UHR mode has a pixel size of 0.25 mm by 0.25 mm at the iso-center, while the conventional (macro) mode is limited to 0.5 mm by 0.5 mm. A set of synthetic lung nodules (two shapes, five sizes, and two radio-densities) was scanned using both the UHR and macro modes and reconstructed with 2 reconstruction kernels (4 sets of images in total). Linear regression analysis was performed to compare measured nodule volumes from CT images to reference volumes. Surface curvature was calculated for each nodule and the full width half maximum (FWHM) of the curvature histogram was used as a shape index to differentiate sphere and star shape nodules. Receiver operating characteristic (ROC) analysis was performed and area under the ROC curve (AUC) was used as a figure of merit for the differentiation task. Results showed strong linear relationship between measured nodule volume and reference standard for both UHR and macro mode. For all nodules, volume estimation was more accurate using UHR mode with sharp kernel (S80f), with lower mean absolute percent error (MAPE) (6.5%) compared with macro mode (11.1% to 12.9%). The improvement of volume measurement from UHR mode was more evident particularly for small nodule size (3mm, 5mm), or star-shape nodules. Images from UHR mode with sharp kernel (S80f) consistently demonstrated the best performance (AUC = 0.85) when separating star from sphere shape nodules among all acquisition and reconstruction modes. Our results showed the advantages of UHR mode on a PCD CT scanner in lung nodule characterization. Various clinical applications, including quantitative imaging, can benefit substantially from this high resolution mode.

Higher TSH can be used as an additional risk factor in prediction of malignancy in euthyroid thyroid nodules evaluated by cytology based on Bethesda system.

Recently, it has been suggested that thyrotropin (TSH) concentration can be used as a marker for prediction of thyroid malignancy. In this study, we aimed to investigate the association between TSH levels and prediction of malignancy in euthyroid patients with different Bethesda categories. The data of 1433 euthyroid patients with 3206 thyroid nodules who underwent thyroidectomy were screened retrospectively. The preoperative cytology results, thyroid function tests, thyroid autoantibodies, and presence of histopathological Hashimoto's thyroiditis (HT) were recorded. Of the 1433 patients, 585 (40.8%) had malignant and 848 (59.2%) had benign histopathology. Malignant group had smaller nodule size, elevated TSH levels, and higher rate of presence of HT compared to benign group (p<0.001, all). Cytology results of 3206 nodules were as follows: 832 nondiagnostic (ND), 1666 benign, 392 atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), 68 follicular neoplasm/suspicious for follicular neoplasm (FN/SFN), 133 suspicious for malignancy (SM), and 115 malignant. Both SM and malignant cytology groups had higher TSH levels than other 4 Bethesda categories (p<0.05, all). Benign cytology group had significantly lower TSH levels compared to other cytology groups (p<0.05, all). Patients with malignant final histopathology in ND and AUS/FLUS cytology groups had significantly higher TSH levels compared to patients with benign final histopathology (p<0.05, all). Moreover, TSH levels showed to increase from Bethesda categories II to VI. In addition to cytology, higher TSH levels can be used as a supplementary marker in prediction of malignancy in certain Bethesda categories.

Thyroid carcinoma in children, adolescents and adults, both spontaneous and after childhood radiation exposure.

Thyroid carcinoma is the most common second malignancy for childhood cancer survivors. Radiation exposure is linked to risk. Thyroid nodules in children have a high risk for malignancy, whether spontaneous or after radiation. Due to the extremely limited available paediatric data, we sought to review a series of patients with thyroid carcinoma, seen over 25 years. Forty-six patients were identified. Thirty-nine (84.8 %) had papillary thyroid carcinoma, five (10.9 %) follicular carcinoma and 2 (4.3 %) medullary thyroid carcinoma (MEN2B). Thirty-three (71.7 %) had childhood radiation exposure (17 females) with thyroid malignancy occurring 6-37 years later. The smallest nodule size found on surveillance to have thyroid malignancy was 4 mm. Thyroid cancer in patients 16 years and under was seen in 22 patients (47.8 %). All had total thyroidectomy, with initial central node clearance from 2005. Diagnostic rTSH stimulated I(123) scan was followed by ablative I(131) if any uptake was seen. Sixteen (32.6 %) had metastases. Twenty-four (52.2 %) had I(131), four requiring multiple courses. Forty-two remain alive and well. Ultrasound screening is required for early diagnosis as small nodule size is not predictive of benign histology or absence of metastases. Central node clearance provides better outcome. Despite metastatic disease at presentation for some, prognosis is favourable. • Incidence of thyroid cancer has been increasing and radiation exposure in childhood cancer survivors is clearly linked to risk. • Published guidelines in many places can only provide very low level evidence due to extremely limited available paediatric data. What is New: • Paper provides good evidence to confirm existing views with the largest cohort of thyroid cancer reported to date in the paediatric age group in Australia, and the largest cohort in Australia where there have been specific high risks of radiation exposure. The only other reported larger studies have come from the Children's Oncology Group and Childhood Cancer Survivor Study [24]. • Using diagnostic rTSH stimulated I(123) scan 6 weeks after surgery helps to determine if radioactive iodine ablation is necessary and limits unnecessary bone marrow exposure for young patients in whom future leukaemia is of greater concern.

Statistical analysis of lung nodule volume measurements with CT in a large-scale phantom study.

To determine inter-related factors that contribute substantially to measurement error of pulmonary nodule measurements with CT by assessing a large-scale dataset of phantom scans and to quantitatively validate the repeatability and reproducibility of a subset containing nodules and CT acquisitions consistent with the Quantitative Imaging Biomarker Alliance (QIBA) metrology recommendations. The dataset has about 40 000 volume measurements of 48 nodules (5-20 mm, four shapes, three radiodensities) estimated by a matched-filter estimator from CT images involving 72 imaging protocols. Technical assessment was performed under a framework suggested by QIBA, which aimed to minimize the inconsistency of terminologies and techniques used in the literature. Accuracy and precision of lung nodule volume measurements were examined by analyzing the linearity, bias, variance, root mean square error (RMSE), repeatability, reproducibility, and significant and substantial factors that contribute to the measurement error. Statistical methodologies including linear regression, analysis of variance, and restricted maximum likelihood were applied to estimate the aforementioned metrics. The analysis was performed on both the whole dataset and a subset meeting the criteria proposed in the QIBA Profile document. Strong linearity was observed for all data. Size, slice thickness × collimation, and randomness in attachment to vessels or chest wall were the main sources of measurement error. Grouping the data by nodule size and slice thickness × collimation, the standard deviation (3.9%-28%), and RMSE (4.4%-68%) tended to increase with smaller nodule size and larger slice thickness. For 5, 8, 10, and 20 mm nodules with reconstruction slice thickness ≤0.8, 3, 3, and 5 mm, respectively, the measurements were almost unbiased (-3.0% to 3.0%). Repeatability coefficients (RCs) were from 6.2% to 40%. Pitch of 0.9, detail kernel, and smaller slice thicknesses yielded better (smaller) RCs than those from pitch of 1.2, medium kernel, and larger slice thicknesses. Exposure showed no impact on RC. The overall reproducibility coefficient (RDC) was 45%, and reduced to about 20%-30% when the slice thickness and collimation were fixed. For nodules and CT imaging complying with the QIBA Profile (QIBA Profile subset), the measurements were highly repeatable and reproducible in spite of variations in nodule characteristics and imaging protocols. The overall measurement error was small and mostly due to the randomness in attachment. The bias, standard deviation, and RMSE grouped by nodule size and slice thickness × collimation in the QIBA Profile subset were within ±3%, 4%, and 5%, respectively. RCs are within 11% and the overall RDC is equal to 11%. The authors have performed a comprehensive technical assessment of lung nodule volumetry with a matched-filter estimator from CT scans of synthetic nodules and identified the main sources of measurement error among various nodule characteristics and imaging parameters. The results confirm that the QIBA Profile set is highly repeatable and reproducible. These phantom study results can serve as a bound on the clinical performance achievable with volumetric CT measurements of pulmonary nodules.

Ultrasound-guided thyroid nodule biopsy: outcomes and correlation with imaging features

Background and purposeThyroid nodules are ubiquitous on ultrasound but have a low risk of malignancy. Hence, risk stratification is essential before biopysing them. We aim to (a) determine the frequency and predictors of nondiagnostic fine needle aspiration biopsy (FNAB) of thyroid nodules and (b) seek correlation between sonographic features and biopsy outcomes. MethodsBetween January 2010 and April 2013, 559 thyroid nodules underwent ultrasound-guided FNAB. Demographic information was obtained. Prebiopsy ultrasound images were reviewed for size, multiplicity, echotexture, shape, margins, vascularity, calcifications, cervical lymphadenopathy, and extrathyroid extension. Univariate and multivariate logistic regression analyses adjusting for the correlation between multiple nodules obtained from the same patient were performed. ResultsA total of 10.6% of the biopsies were nondiagnostic. Male gender [adjusted odds ratio (OR)=3.78, 95% confidence interval (CI) 1.87–7.66, P<.001] and a taller-than-wide shape (adjusted OR=3.22, 95% CI 1.34–7.75, P=.009) were independent predictors of a nondiagnostic FNAB. There was no significant association with cystic echotexture or a smaller nodule size. Well-defined irregular margins, microcalcifications, and coarse calcifications were independent predictors of malignancy, with specificities above 96% but low sensitivities (59.3%, 44.4%, and 11.1%, respectively). All nodules with cervical lymphadenopathy were malignant. If biopsy is performed when at least one of the above four features are present, the sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of predicting malignancy are 81.5%, 93.1%, 11.8 and 0.2 respectively. All purely cystic nodules and spongiform nodules were benign. ConclusionsMale gender and taller-than-wide thyroid nodules are independent risk factors for a nondiagnostic FNAB. Prudent use of a combination of sonographic features can help to risk-stratify thyroid nodules for FNAB and may reduce unwarranted FNABs.

Papillary Thyroid Cancer and Hashimoto’s Thyroiditis: An Association Less Understood

Hashimoto's thyroiditis (HT), part of the spectrum of autoimmune thyroid diseases is a major cause of thyroid hypofunction worldwide. Papillary thyroid carcinoma (PTC), the most prevalent of all thyroid carcinomas has been associated with HT. Literature on this association are based on preoperative FNA or post thyroidectomy histopathology reports, which are subject to potential biases. Molecular, hormonal and histopathalogical basis of this association has been hypothesized, however a definite causal association has not been proved till date. This review aims to study the basis of this association and clinical features and management of HT concurrent with PTC. There are no distinctive clinical or radiological features that categorically differentiates HT concurrent with PTC from PTC or which can pick up a nodule harboring PTC in setting of HT. Smaller nodule size and radiological features like hypoechogenecity; hyper vascularity and calcification in a clinical setting of hypothyroidism have a higher odds ratio for malignancy and merit further investigations. PTC associated with HT has been seen to be less aggressive with earlier presentation with lesser chances of extra thyroidal extension and lymph nodal metastasis. The management and follow up of PTC in HT is no different from that of PTC alone. The prognosis of PTC concurrent with HT is better compared to age and stage matched PTC in terms of lower recurrence and disease free and overall survival.